During initial fluid resuscitation, urine output helps guide fluid resuscitation needs. Measuring hourly intake and output is most effective in determining the needs for additional fluid infusion than is urine output alone. Blood urea nitrogen may be used to monitor volume status, but it is affected by the hypermetabolic state seen after burns, so it is not the optimal measure of intravascular fluid status. Daily weight measures overall volume status, not just intravascular volume. Serum potassium is released with tissue damage and thus is not the optimum measure of intravascular fluid status.

2. In patients with extensive burns, edema occurs in both burned and unburned areas because of:

a.

catecholamine-induced vasoconstriction.

b.

decreased glomerular filtration.

c.

increased capillary permeability.

d.

loss of integument barrier.

ANS: C

Capillary permeability is altered in burns beyond the area of tissue damage, resulting in significant shift of proteins, fluid, and electrolytes resulting in edema (third spacing). Catecholamine-induced vasoconstriction does not produce edema. Decreased glomerular filtration may cause fluid retention, but it is not responsible for the extensive edema seen after burn injury. Loss of integument barrier does not cause edema.

The loss of skin as the primary barrier against microorganisms and activation of the inflammatory response cascades results in immunosuppression, placing the patient at an increased risk of infection. A systemic inflammatory response (SIRS) also increases the risk of acute kidney injury in the presence of poor tissue perfusion. Acute respiratory distress syndrome is also a potential complication, but the risk of infection is greater because of the loss of the skin barrier. Catecholamine release and gastrointestinal ischemia are the causes of stress ulcers.

4. The nurse is caring for a burn-injured patient who weighs 154 pounds, and the burn injury covers 50% of his body surface area. The nurse calculates the fluid needs for the first 24 hours after a burn injury using a standard fluid resuscitation formula of 4 mL/kg/% burn of intravenous (IV) fluid for the first 24 hours. The nurse plans to administer what amount of fluid in the first 24 hours?

5. The nurse is caring for a patient who has circumferential full-thickness burns of his forearm? A priority in the plan of care is :

a.

Keeping the extremity in a dependent position

b.

Active and passive range of motion every hour.

c.

Preparing for an escharotomy as a prophylactic measure

d.

Splinting the forearm

ANS: B

Special attention is given to circumferential (completely surrounding a body part) full thickness

burns of the extremities. Pressure from bands of eschar or from edema that develops as resuscitation proceeds may impair blood flow to underlying and distal tissue. Therefore, extremities are elevated to reduce edema. Active or passive range-of-motion (ROM) exercises are performed every hour for 5 minutes to increase venous return and to minimize edema. Peripheral pulses are assessed every hour, especially in circumferential burns of the extremities, to confirm adequate circulation. If signs and symptoms of compartment syndrome are present on serial examination, preparation is made for an escharotomy to relieve pressure and to restore circulation.

DIF: Cognitive Level: Application REF: p. 638

OBJ: Formulate a plan of care for the patient with a burn injury.

TOP: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

6. The patient asks the nurse if the placement of the autograft over his full-thickness burn will be the only surgical intervention needed to close his wound. The nurses best response would be:

a.

Unfortunately, an autograft skin is a temporary graft and a second surgery will be needed to close the wound.

b.

An autograft is a biological dressing that will eventually be replaced by your body generating new tissue.

c.

Yes, an autograft will transfer your own skin from one area of your body to cover the burn wound.

d.

Unfortunately, autografts frequently do not adhere well to burn wounds and a xenograft will be necessary to close the wound.

ANS: C

The autograft is the only permanent method of grafting and it uses the patients own tissue to cover the burn wound. Autografting is permanent and does not require a second surgery unless the graft fails. A biological or biosynthetic graft or dressing is a temporary wound covering. A xenograft is from an animal, usually pig skin and is a temporary graft.

DIF: Cognitive Level: Application REF: p. 647

OBJ: Formulate a plan of care for the patient with a burn injury.

TOP: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

7. A patient admitted with severe burns to his face and hands is showing signs of extreme agitation. The nurse should explore the mechanism of burn injury possibly related to:

a.

excessive alcohol use.

b.

methamphetamine use.

c.

posttraumatic stress disorder.

d.

subacute delirium.

ANS: B

A vague or inconsistent injury history, burns to the face and hands, and signs of agitation or substance withdrawal should alert the nurse to a potential methamphetamine-related injury.

8. The nurse is caring for patient who has been struck by lightning. Because of the nature of the injury, the nurse assesses the patient for which of the following?

a.

Central nervous system deficits

b.

Contractures

c.

Infection

d.

Stress ulcers

ANS: A

Lightning injury frequently causes cardiopulmonary arrest. However, of those patients who survive, 70% will have transient central nervous system deficits. Contractures, infection, and stress ulcer risks are no greater than with other causes of burn injury.

9. The nurse is providing care to manage the pain of a patient with burns. The physician has ordered opiates to be given intramuscularly. The nurse contacts the physician to change the order to intravenous administration because:

a.

intramuscular injections cause additional skin disruption.

b.

burn pain is so severe it requires relief by the fastest route available.

Edema and impaired circulation of the soft tissue interfere with absorption of medications administered subcutaneously or intramuscularly. Even though it is true intramuscular injections disrupt tissue, medication absorption is not effective. Burn pain is severe and intravenous administration is desired to relieve pain, but this is not the physiological basis for giving medications intravenously. Hypermetabolism affects medication effectiveness but is not the rationale for administering opioids intravenously.

DIF: Cognitive Level: Comprehension REF: pp. 642-643

OBJ: Formulate a plan of care for the patient with a burn injury.

TOP: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

10. When paramedics notice singed hairs in the nose of a burn patient, it is recommended that the patient be intubated. What is the reasoning for the immediate intubation?

a.

Carbon monoxide poisoning always occurs when soot is visible.

b.

Inhalation injury above the glottis may cause significant edema that obstructs the airway.

c.

The patient will have a copious amount of mucus that will need to be suctioned.

d.

The singed hairs and soot in the nostrils will cause dysfunction of cilia in the airways.

ANS: B

In inhalation injury, the airway may become edematous quickly, making intubation difficult. Early intubation is recommended to protect the airway. Carbon monoxide poisoning may be present, but singed nose hairs are neither a symptom nor a reason for early intubation. Management of secretions is not an indication for intubation. Singed hairs and soot are more commonly symptoms of injury above the glottis rather than lower airway, below-the-glottis, signs and symptoms that will interfere with oxygenation and ventilation.

11. A patient with a 60% burn in the acute phase of treatment develops a tense abdomen, decreasing urine output, hypercapnia, and hypoxemia. Based on this assessment, the nurse anticipates interventions to evaluate and treat the patient for:

a.

acute kidney injury.

b.

acute respiratory distress syndrome.

c.

intraabdominal hypertension.

d.

disseminated intravascular coagulation disorder.

ANS: C

Intraabdominal hypertension (IAH) is a serious complication caused by circumferential torso burn injuries or edema from aggressive fluid resuscitation. Signs and symptoms of IAH include tense abdomen, decreased urine output, and worsening pulmonary function. Acute kidney injury will not result from aggressive fluid resuscitation. Acute respiratory distress syndrome would present with signs of hypoxia and hypercarbia, but not a tense abdomen. Disseminated intravascular disorder may present as a tense abdomen if there is active bleeding, but it would not present with pulmonary symptoms.

12. An elderly individual from an assisted living facility presents with severe scald burns to the buttocks and back of the thighs. The caregiver from the ALF accompanies the patient to the emergency department and states that the bath water was too hot and that the patient sat in the water too long. What should the nurse do?

a.

Ask the caregiver at what temperature the water heater is set in the home.

b.

Ask the caregiver to step out while examining the patients burn injury.

c.

Immediately contact the police to report the suspected elder abuse.

d.

Ask the caregiver to describe exactly how the injury occurred.

ANS: B

In cases of suspected abuse, especially in vulnerable patients such as children, elderly, and mentally impaired, it is important to assess the injured patient separately from the caregiver. While obtaining safety information on the temperature of the water heater is important, it is not a priority assessment question. The nurse should follow the hospital protocol for contacting appropriate authorities concerning suspected abuse, which may include contacting the police or social services. Asking the caregiver to describe how the injury occurred is important (e.g., there may be discrepancies in the physical assessment and reported mechanism of burn injury); however, examining the patient away from the caregiver is a priority.

13. Silver is used as an ingredient in many burn dressings because it:

a.

stimulates tissue granulation.

b.

is effective against a wide spectrum of wound pathogens.

c.

provides topical pain relief.

d.

stimulates wound healing.

ANS: B

Silver is an ingredient in many dressings because it helps prevent infection against a wide spectrum of common pathogens. Silver does not stimulate tissue granulation; nor does it provide pain relief or stimulate wound healing processes.

DIF: Cognitive Level: Comprehension REF: p. 645 | Table 20-4

OBJ: Formulate a plan of care for the patient with a burn injury.

TOP: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

14. The nurse understands that negative-pressure wound therapy may be used in the treatment of partial-thickness burn wounds to do which of the following?

a.

Maintain a closed wound system to decrease the risk of infection.

b.

Remove excessive wound fluid and promote moist wound healing.

c.

Increase patient mobility with large burn wounds.

d.

Quantify wound drainage amount for more accurate output assessment.

ANS: B

Negative-pressure wound therapy can be used to treat grafts or partial-thickness burns by decompressing edematous interstitial spaces that enhance local perfusion, optimizing wound healing. This therapy also provides a moist wound-healing environment. The system is closed and may reduce the risk of infection but may not prevent infection. Patients are less mobile because the system needs an electrical source to function. Wound drainage is quantified by using the negative-pressure wound therapy system, but this is not a primary indication for the therapy.

DIF: Cognitive Level: Comprehension REF: p. 646

OBJ: Formulate a plan of care for the patient with a burn injury.

TOP: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

15. The nurse is caring for a patient with an electrical injury. The nurse understands that patients with electrical injury are at a high risk for acute kidney injury secondary to:

a.

hypervolemia from burn resuscitation.

b.

increased incidence of ureteral stones.

c.

nephrotoxic antibiotics for prevention of infection.

d.

release of myoglobin from injured tissues.

ANS: D

Myoglobin is released during electrical injury and is a risk factor for rhabdomyolysis and acute kidney injury. Hypervolemia is not a cause of acute kidney injury. Ureteral stones and nephrotoxic antibiotics may cause acute kidney injury but is not associated with the electrical injury.

16. The nurse is caring for a patient with a chemical burn injury. The priority nursing intervention is to:

a.

remove the patients clothes and flush the area with water.

b.

apply saline compresses.

c.

contact a poison control center for directions on neutralizing agents.

d.

remove all jewelry.

ANS: A

As long as the chemical remains in contact with the skin, burn damage will result. Priority interventions are to remove the patients clothes, brush loose chemical away from the skin and apply water for at least 30 minutes. Water needs to washed away from the body, not be applied as compresses. Contacting poison control may be helpful in obtaining more information on the systemic effects of the chemical, but it is not a priority intervention. Jewelry should be removed, but this is not as high a priority as removing the chemical and stopping the chemical burning process through continuous flushing with water.

DIF: Cognitive Level: Application REF: p. 616, 632

OBJ: Describe the pathophysiology of burns.

TOP: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

17. Patients with burns may have mesh grafts or sheet grafts. Which of the following sites is most likely to have a sheet graft applied?

a.

Arm

b.

Face

c.

Leg

d.

Chest

ANS: B

A sheet graft is more likely to be used on the face and hands because the cosmetic effects are more optimal. Meshed grafts are more commonly used elsewhere on the body (e.g., arm, leg, chest, etc.).

DIF: Cognitive Level: Comprehension REF: p. 649 | Table 20-6

OBJ: Formulate a plan of care for the patient with a burn injury.

TOP: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

18. The nurse is caring for a patient who has undergone skin grafting of the face and arms for burn wound treatment. A primary nursing diagnosis is:

a.

altered nutrition, less than body requirements.

b.

body image disturbance.

c.

decreased cardiac output.

d.

fluid volume deficit.

ANS: B

Burns, scarring, and skin grafting can all affect appearance. Body image disturbances may result. Nutritional support is started early in management of the patient with burns, and there is no indication that this patient has a nutritional deficit. Nursing care plan priorities would also continue to focus on nutritional needs to optimize healing. Decreased cardiac output and fluid volume deficit should not be priority concerns during the wound closure phase of burn wound management by grafting.

DIF: Cognitive Level: Application REF: p. 650

OBJ: Relate the nursing diagnoses, outcomes, and interventions for the burned patient.

19. The nurse is assisting the patient to select foods from the menu that will promote wound healing. Which statement indicates the nurses knowledge of nutritional goals?

a.

Avoid foods that have saturated fats. Fats interfere with the ability of the burn wound to heal.

b.

Choose foods that are high in protein, such as meat, eggs, and beans. These help the burns to heal.

c.

It is important to choose foods like bread and pasta that are high in carbohydrates. These foods will give you energy and help you to heal faster.

d.

Select foods that have lots of fiber, such as whole grains and fruits. These will promote removal of toxins from the body that interfere with healing.

ANS: B

Nutritional therapy must be instituted immediately after burn injury to meet the high metabolic demands of the body. Oral diets should be high in calories and high in protein to meet the demands of the body.

20. A burn patient in the rehabilitation phase of injury is increasingly anxious and unable to sleep. The nurse should consult with the provider to further assess the patient for:

a.

acute delirium.

b.

posttraumatic stress disorder.

c.

suicidal intentions.

d.

bipolar disorder.

ANS: B

Burn-injured patients experience psychologically devastating injuries in addition to physical injuries. Burn patients that demonstrate changes in behavior, anxiety, insomnia, regression, and acting out should be evaluated for posttraumatic stress disorder. Acute delirium is more likely to occur during the acute phase of injury. Suicidal ideations should always be addressed if the patient expresses or shows signs of suicidal thoughts. Burn-injured patients may have an underlying mental health disorder that requires treatment, such as bipolar disorder or schizophrenia.

DIF: Cognitive Level: Application REF: pp. 650-651

OBJ: Formulate a plan of care for the patient with a burn injury.

TOP: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

21. The nurse is planning care to meet the patients pain management needs related to burn treatment. The patient is alert, oriented, and follows commands. The pain is worse during the day when various treatments are scheduled. Which statement to the physician best indicates the nurses knowledge of pain management for this patient?

a.

Can we ask the music therapist to come by each morning to see if that will help the patients pain?

b.

The patients pain is often unrelieved. I suggest that we also add benzodiazepines to the opioids around the clock.

c.

The patients pain is often unrelieved. It would be best if we can schedule the opioids around the clock.

d.

The patients pain varies depending on the treatment given. Can we try patient-controlled analgesia to see if that helps the patient better?

ANS: D

Patient-controlled analgesia allows the patient with burns to self-medicate for pain, thus providing independence with pain management strategies. Nonpharmacological pain strategies may provide helpful adjuncts to pain interventions. Scheduled pain medications and anxiolytic agents, although helpful, do not put the control of pain management with the patient.

22. The nurse is conducting an admission assessment of an 82-year-old patient who sustained a 12% burn from spilling hot coffee on the hand and arm. Which statement is of priority to assist in planning treatment?

a.

Do you live alone?

b.

Do you have any drug or food allergies?

c.

Do you have a heart condition or heart failure?

d.

Have you had any surgeries?

ANS: C

Many variables influence the outcome of elderly burn patient mortality, including preinjury hydration status, nutrition status, and comorbid diseases, especially heart failure. Assessment questions should include, as a priority, information about the patients cardiovascular status, including heart failure. Obtaining food or drug allergy information is also important along with other past medical history, including past surgeries. Information on the patients living arrangements is an important safety consideration for discharge planning.

23. A 63-year-old patient is admitted with new onset fever; flulike symptoms; blisters over her arms, chest, and neck; and red, painful, oral mucous membranes. The patient should be further evaluated for which possible nonburn injured skin disorder?

1. Which of the following statements about the pain management of a burn victim are true? (Select all that apply.)

a.

Additional pain medication may be needed because of rapid body metabolism.

b.

Pain medication should be given before procedures such as debridement, dressing changes, and physical therapy.

c.

Patients with a history of drug and alcohol abuse will require higher doses of pain medication.

d.

The intramuscular route is preferred for pain medication administration.

ANS: A, B, C

The rapid metabolism associated with burn injury may require additional pain medication. Many of the procedures associated with burn wounds are painful, such as dressing changes. Adequate pain medication should be given prior to the procedures. Edema in burned patients alters the absorption of medications that are injected intramuscularly; therefore, drugs must be administered by the IV route.

DIF: Cognitive Level: Application REF: pp. 644-645

OBJ: Relate the nursing diagnoses, outcomes, and interventions for the burned patient.

TOP: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

2. Which of the following factors increase the burn patients risk for venous thromboembolism? (Select all that apply.)

a.

Burn injury less than 10%

b.

Bedrest

c.

Burns to lower extremities

d.

Electrical burn injury

e.

Delayed fluid resuscitation

ANS: B, C, E

Venous thromboembolism (VTE) is a significant risk for patients who have thermal injury, venous stasis associated with immobility/bedrest, hypercoagulability seen with burn injuries greater than 10% TBSA, and hypovolemia associated with delayed fluid resuscitation. Burns to lower extremities will limit mobility and use of sequential compression devices, increasing the potential risk for VTE. Electrical burn injury may pose a risk for VTE; however, VTE is more closely associated with thermal injuries greater than 10% TBSA.

3. The nurse is caring for a patient with burns to the hands, feet, and major joints. The nurse plans care to include which of the following? (Select all that apply.)

a.

Applying splints that maintain the extremity in an extended position

b.

Implementing passive or active range-of-motion exercises

c.

Keeping the limbs as immobile as possible

d.

Wrapping fingers and toes individually with bandages

ANS: A, B, D

It is important to avoid immobility in patients with burns of the hands, feet, or major joints. Measures must be taken to maintain the function of the hands, feet, and major joints. Nursing interventions to maintain range of motion, applying splits to keep the extremities in a position of function, and individually wrapping fingers and toes are necessary to maintain function of the hands, feet, and joints. Effective pain management is necessary to encourage mobility.

4. Which of the following infection control strategies should the nurse implement to decrease the risk of infection in the burn-injured patient? (Select all that apply.)

a.

Apply topical antibacterial wound ointments/dressings.

b.

Change indwelling urinary catheter every 7 days.

c.

Daily assess the need for central IV catheters.

d.

Restrict family visitation.

e.

Maintain strict aseptic technique during burn wound management.

ANS: A, C, E

Nurses can help reduce the risk of infection by using topical antibacterial wound ointments and dressings as prescribed, daily questioning the need for invasive devices such as central IV access and indwelling urinary catheters, and maintaining aseptic technique during all care provided to the patient. Changing the indwelling urinary catheter will not reduce the risk of infection; wound care is achieved by aseptic technique; and restricting family is not an intervention related to infection prevention.

6. An autograft is used to optimally treat a partial- or full-thickness wound that: (Select all that apply.)

a.

involves a joint.

b.

involves the face, hands, or feet.

c.

is infected.

d.

requires more than 2 weeks for healing.

ANS: A, B, D

Autograft skin will allow for faster healing with less scar formation and a shorter hospitalization.

DIF: Cognitive Level: Comprehension REF: p. 647

OBJ: Formulate a plan of care for the patient with a burn injury.

TOP: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

COMPLETION

1. The correct priority order of actions in prehospital primary survey for burn injuries is: _______________, _______________, _______________, _______________. (Put a comma and space between each answer choice.)

a. Assess ABCs and cervical spine.

b. Provide oxygen therapy if smoke inhalation is suspected.

c. Make rapid head-to-toe assessment to rule out additional trauma.

d. Stop the burning process and prevent further injury.

ANS:

D, A, B, C

Early care has a positive impact on recovery. The first priority is to stop the burning process and prevent further injury. At this point, you initiate the primary survey, which is to assess the ABCs and cervical spine. Oxygen therapy follows the ABCs. The secondary survey includes further assessment for additional injuries.